The 2nd International Meeting of Public Health 2016 with theme Public Health Perspective of Sustainable Development Goals: The Challenges and Opportunities in Asia-Pacific Region Volume 2018 Conference Paper Depression, Anxiety, Stress and Perceived Social Support Among Breast Cancer Survivors in Tertiary Hospital in Malaysia Zakaria Nurasyikin 1, Mahmood MOHD. Ihsani 1, Zakariahazli 1, Syed Zakaria Syed Zulkifli 1, Mohamed Nahar Azmi 1, Ismail Fuad 1, Muhamad Rohaizak 2, Abd. Talibruzita 1, and Md. Isa Zaleha 1 1 Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center (UKMMC) Jalan Yaacob Latif, 56000 Cheras, Kuala Lumpur, Malaysia 2 Faculty of Medicine, Universiti Malaya Medical Center (UMMC) Jalan Universiti, 59100 Petaling Jaya, Kuala Lumpur, Malaysia Corresponding Author: Zakaria Nurasyikin nurasyikinzeq@gmail.com Received: 21 January 2018 Accepted: 8 April 2018 Published: 17 May 2018 Publishing services provided by Knowledge E Zakaria Nurasyikin et al. This article is distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use and redistribution provided that the original author and source are credited. Selection and Peer-review under the responsibility of the 2nd International Meeting of Public Health 2016 Conference Committee. Abstract The emotional distress and psychosocial factors are links to worst quality of life among cancer patients as well as survivors. It gives negative impact to the survivors and their family. The objective of the study was to determine the correlation of depression, anxiety and stress with perceived social support among breast cancer survivors. This is a baseline finding of an educational intervention study. A total of 131 female breast cancer survivors were recruited while they went for their appointment at the Oncology clinic in one of the Tertiary Hospital in Kuala Lumpur. Baseline data was collected using the Depression, Anxiety and Stress (DASS) and Multidimensional Scale of Perceived Social Support (MSPSS) questionnaires. Descriptive analysis and correlation tests were used to determine the strength of a linear relationship between depression, anxiety and stress with perceived social support. The descriptive analysis showed that breast cancer survivors had a higher prevalence of anxiety (30.5%) as compared to depression (14.5%) and stress (12.2%). Perceived social support was higher among family support (96.2%) as compared to significant others (84.7%) and friend (71.8%). There was a fair negative correlation between: (i) depression and family support (r = -0.372, p < 0.001), and (ii) stress and family support (r = -0.342, p < 0.001). Other domains had a poor correlation (r < 0.030). The finding shows that social support from the family and significant others have a significant but fair inverse association with the emotional aspect (depression and stress) of breast cancer survivors. Keywords: Correlation, DASS, MSPSS, breast cancer, Malaysia. How to cite this article: Zakaria Nurasyikin, Mahmood MOHD. Ihsani, Zakariahazli, Syed Zakaria Syed Zulkifli, Mohamed Nahar Azmi, Ismail Fuad, Muhamad Rohaizak, Abd. Talibruzita, and Md. Isa Zaleha, (2018), Depression, Anxiety, Stress and Perceived Social Support Among Breast Cancer Survivors in Tertiary Hospital in Malaysia in The 2nd International Meeting of Public Health 2016 with theme Public Health Perspective of Sustainable Development Goals: The Challenges and Opportunities in Asia-Pacific Region, KnE Life Sciences, pages 232 240. DOI 10.18502/kls.v4i4.2282 Page 232
1. INTRODUCTION Breast cancers become the highest ranking compare to other type of cancer among women s cancer patient in Malaysia. The International Agency for Research in Cancer (GLOBOCAN) 2012 estimated the age-standardised rate (ASR) of breast cancer in Malaysia as 38.7 per 100,000 with 5410 new cases in 2012. Breast cancer survivors in this study refer to women breast cancer patients who are already past 6 months complete the surgery, chemotherapy and radiotherapy. A study of depression, anxiety and cancer related distress post-treatment for breast cancer for younger women and college education patients demonstrated greater distress [6]. Depression, anxiety and stress was varies from each other. The symptoms may include hopelessness, fatigue, physical and mentally pain. Depression makes it hard to function and enjoy life like before they did. People with anxiety feeling may have anxious symptoms that they are not so uncomfortable in daily life [12]. Social support from family provides patients with practical help and can buffer the burden of survivors. Social support is to maintain the individual by supporting the emotional aspect and adaptation to face stress and threats to healththe stresses of living with the fear of recurrence of the disease, they need high social support from family and friends (Miller 2013) [4]. 2. METHODS 2.1. Study design and respondents This study was carried out in Oncology and Radiotherapy clinic at one of the Tertiary Hospital in Kuala Lumpur, Malaysia. Breast cancer survivors were recruited from list name in their appointment follow up treatment list. The survivors were chosen based on inclusive criteria; understand Malay and English language, Malaysian citizenship, age from 18 to 70, diagnosed in stage I, II and III only and complete primary treatment; surgery, radiotherapy and chemotherapy at least past six months. While for the exclusion criteria we omitted those who are pregnant and breastfeeding, having chronic kidney diseases, mental disorder and rheumatoid arthritis. Written consent was obtained from survivors after the researcher telling the patient s information sheet. The simple random sampling using list name from the clinic appointment were applied to choose respondents. DOI 10.18502/kls.v4i4.2282 Page 233
2.2. Questionnaires The questionnaire booklet was divided to five section; socio-demographic, medical report, social life, depression anxiety stress scale and perceived social support of respondents. The socio-demographic section included age, education level, household income, occupation and married or unmarried. Social life section asked about involvement to cancer support group and living with whom. Medical report section asked about stage of cancer, grade (aggressiveness) of cancer cell, year of diagnosed and type of treatment underwent. The Depression, Anxiety and Stress Scale (DASS) were used to assess symptoms of depression, anxiety, and stress using a 21-item questionnaire. Each item is rated on a 4-point Likert scale ranging from 0 (did not apply to me) to 3 (applied to me very much or most of the time). The Multidimensional Scale of Perceived Social Support (MSPSS) was used to assess the perceived social support using a 12-item questionnaire. Each item rated on a 7-point Likertscale ranging from 1 (Very Strongly Disagree) to 7 (Very Strongly Agree). The section was filled up by survivors themselves. They may ask explanation from the researchers that available in the clinic. 2.3. Statistical analysis All analysis were done using IBM SPPS Statistics software version 23. The descriptive analysis and Pearson s correlation tests were used to determine the strength of a linear relationship between depression, anxiety and stress with perceived social support among breast cancer survivors. 3. RESULTS 3.1. Demographic background The respondents consisted of 131 women breast cancer survivors who already completed the primary treatment; surgery, radiotherapy and chemotherapy at least for past six months at one centre of tertiary hospital in Malaysia. Most respondents were Malay; 65.6% compared to non-malay (Table 1). While for the age distribution, 50 to 59 years old respondents covered almost 42.7% of the whole respondents. Meanwhile for working status, almost equal of the respondents were working (50.4%). Most DOI 10.18502/kls.v4i4.2282 Page 234
respondents had secondary education 54.2 % compare primary and tertiary education. Income status of the respondents was that majority in range Ringgit Malaysia (RM) 2999 and lower compared to higher income group; RM3000 to 5000, RM5001 and higher. Almost one third of the respondents (70.2 %) were married. The medical record shows among respondents are majority in stage II (50.4%), undergo for single mastectomy (48.9%) compared to lumpectomy and double mastectomy; receive radiotherapy (86.3%) and chemotherapy (79.4%), not involve with any cancer support group (71.8%) and take supplement in their diet (64.9%). Table 1: Characteristic of Respondents (n=131). n % Age 49 39 29.8 50 59 56 42.7 60 36 27.5 Race Malay 86 65.6 Non Malay 45 34.4 Education Primary 19 14.5 Secondary 71 54.2 Tertiary 41 31.3 Income (Malaysian Ringgit) 2999 58 44.3 3000-5000 40 30.5 5000 33 25.2 Occupation Working 66 50.4 Housewife 65 49.6 Marital status Single 14 10.7 Married 92 70.2 Widowed 25 19.1 Cancer stage (previous diagnosed) I 37 28.2 II 66 50.4 III 28 21.4 Surgery Lumpectomy 62 47.3 Mastectomy 64 48.9 Double mastectomy 5 3.8 Radiotherapy DOI 10.18502/kls.v4i4.2282 Page 235
n % No 18 13.7 Yes 113 86.3 Chemotherapy No 27 20.6 Yes 104 79.4 Live with survivors Family 119 90.8 Relatives & alone 12 9.2 Involvement with cancer support group No 94 71.8 Yes 37 28.2 Supplement intake No 46 35.1 Yes 85 64.9 3.2. Depression, anxiety and stress scores among respondents Table 2 showed that most respondents were in a normal level of depression (85.5%, n=112), anxiety (69.5%, n=91) and stress (87.8%, n=115). The mean level of depression was low (2.17± 2.94). While the means level of anxiety and stress were low too (2.76± 2.92, 3.37±3.62) respectively. Table 2: Depression, anxiety and stress among survivors (n=131). DASS N % Mean SD Depression Normal 112 85.5 2.17 2.94 Mild-moderate 14 10.7 Severe-extremely severe 5 3.8 Anxiety Normal 91 69.5 2.76 2.92 Mild-moderate 29 22.1 Severe-extremely severe 11 8.4 Stress Normal 115 87.8 3.37 3.62 Mild-moderate 13 9.9 Severe-extremely severe 3 2.3 Score: Depression= 5-10, Anxiety = 4-7, Stress = 8-12 DOI 10.18502/kls.v4i4.2282 Page 236
3.3. Perceived social support among respondents Most respondents perceived high social support from their family (96.2%, n=126), friends (71.8%, n = 94) and significant others (84.7%, n = 111). The means of family support (24.51) was higher than friends (18.85) and significant others (21.12). The score scale showed the respondent s perceived high social support from their family (6.13) and significant others (5.28). While the respondent s perceived moderate (4.71) social support from their friends. Total of MSPSS was high (5.37) among the respondents. Table 3: Perceived social support among survivors (n=131). MSPSS n % Mean Score scale Family Low 5 3.8 24.51 6.13 High High 126 96.2 Friends Low 37 28.2 18.85 4.71 Moderate High 94 71.8 Significant other Low 20 15.3 21.12 5.28 High high 111 84.7 Total MSPSS 64.49 5.37 High PSS: Perceived social support, SO: Significant Others Score scale: family, friends and SO = mean/4, Total MSPSS = mean/12 Cut off point: low support (1-2.9), moderate support (3-5), high support (5.1-7) Low = score 50% and below, High = score 51% and above PSS 3.4. Depression, anxiety and stress with perceived social support score The aim of this study was to identify the correlation between depression, anxiety and stress with perceived social support scores among respondents. Table 3 showed a significant (p < 0.005) association between depression and support from family (p=0.000), friend (p=0.002) and significant others (p=0.003). A significant (p<0.005) association was also between stress and support from family (p=0.000) and significant others (p=0.001). There was a fair negative correlation between depression and family support (r = -0.372, p<0.001), and stress and family support (r = -0.342, p<0.001). Other domains had a poor correlation (r < 0.030). DOI 10.18502/kls.v4i4.2282 Page 237
Table 4: Association between depression, anxiety and stress with family, friend and significant others. DASS PSS r-value p value Depression Family -0.372 0.000* Friend -0.273 0.002* Significant other -0.257 0.003* Anxiety Family -0.117 0.182 Friend -0.132 0.133 Significant other -0.127 0.149 Stress Family -0.342 0.000* Significant value p < 0.005 Friend -0.235 0.007 Significant other -0.287 0.001* Correlation score: 0=no relationship, ± 0.3=fair, ±=moderate, ±strong (+ positive relationship, negative relationship) 4. DISCUSSION This current study showed the prevalence of depression was 14.5%, anxiety was 30% and of stress was 12.2% among the breast cancer survivors. While the prevalence of depression was higher 22.0% and anxiety was 31.7% among breast cancer patients [8]. The prevalence of anxiety was similar (30% and 31.7%) for both studies, but the prevalence of depression was different (14.5% and 22.2%). The previous study used HADS questionnaire and the respondents were among breast cancer patients not survivors. The prevalences of depression and anxiety were higher among breast cancer patients compared to survivors that may be because of the breast cancer patients were still in the treatment at hospital. The treatment included surgery, chemotherapy and radiotherapy completely will give emotionally impact to them. This study concurred with the study done among breast cancer patients of anxiety and depression which subscales scores of the subjects were relatively low (Ng 2015). Results of this study showed the level of anxiety reduced significantly at 6 and 12 months (Baseline 6 months, p = 0.002; Baseline 12 months, p < 0.001). This group of breast cancer survivors had higher social support among their family and significant others. This study was supported by the study done by (Ng 2015) which were the mean scores of perceived social support of the subjects are relatively high. The mean score for the total scale is 71.50, significant others subscale is 24.53, family subscale is 24.90 and friends subscale is 22.08. Social support especially from family is very important to build up the emotional strength of survivors [3, 4, 10]. DOI 10.18502/kls.v4i4.2282 Page 238
The association of depression, anxiety and stress with social support was negatively fair. The (i) depression and family support (r = -0.372, p<0.001), and (ii) stress and family support (r = -0.342, p<0.001). Result of this study was support by (Ng, 2015) which found that patients who perceived high social support were low in depression and anxiety. Survivors who manage to share their feeling and hope with their family and friend may reduce their fear of recurrence and anxiety about risk of dying (Miller 2013; [2]). 5. CONCLUSION The finding shows that the total of perceived social support is high, and levels of depression, anxiety and stress are normal among respondents. It shows a significant (p<0.001) but fair inverse association between family support and depression (r, - 0.372) and stress (r, -0.342) among respondents. ACKNOWLEDGEMENTS The resercher would like to thank the Universiti Kebangsaan Malaysia Medical Centre (UKMMC) for the fundamental grant (FF-2016-030) and the Ethical Committee for the approval to do data collection among breast cancer survivors. Special thanks to Head of Department, nurses and administration staf of Oncology & Radiotherapy Department of UKMMC and survivors for their cooperation. References [1] Badger T, Segrin C, Dorros SM, Meek P, Lopez AM. 2007. Depression and Anxiety in Women with Breast Cancer and Their Partners. Nursing Res., 56 (1): 44-53. [2] Baqutayan, Shadiya Mohamed Saleh. 2012. The Effect of Anxiety on Breast Cancer Patients. Indian Journal of Psychological Medicine 34.2: 119 123. [3] Barth K, Schneider S, and Vonkanel R. (2010). Lack of Social Support in the Etiology and the Prognosis of Coronary Heart Disease: A Systematic Review and Metaanalysis, Psychosomatic Medicine, vol. 72, no. 3: 229 238. [4] Chou AF, Susan L. Stewart, Robert C.W, and Joan R.2012.Bloom. 2012. Social Support and Survival in Young Women with Breast Carcinoma.Psychooncology.February ; 21(2): 125 133. DOI 10.18502/kls.v4i4.2282 Page 239
[5] Copertaro A, Bracci M, Manzella N, Barbaresi M, Santarelli L. 2014. Low Perceived Social Support Is Associated with CD8+CD57+ Lymphocyte Expansion and Increased TNF- α Levels.Hindawi Publishing Corporation BioMed Research Internationa, Article ID 635784:1-5. [6] Costanzo, E. S., Lutgendorf, S. K., Mattes, M. L., Trehan, S., Robinson, C. B., Tewfik, F., & Roman, S. L. 2007. Adjusting to Lafter Treatment: Distress and Quality of the Life Following Treatment for Breast Cancer. British Journal of Cancer, 97:1625-1631. [7] Globocan.2012. Estimated Cancer incidence, Mortality and Prevalence Worldwide in 2012.Available online at http://globocan.iarc.fr/pages/fact_sheets_ cancer.aspx. Accessed on 8 Nov 2016. [8] Hassan, M. R., Shah, S. A., Ghazi, H. F., Mujar, M. M., Samsuri, M. F. & Baharom, N. 2015. Anxiety and Depression among Breast Cancer Patients in an Urban Setting in Malaysia. Asian Pacific for Cancer Prevention, 16 (9): 4031 4035. [9] Jacobsen PB, Jim HS. 2008. Psychosocial Interventions for Anxiety and Depression in Adult Cancer Patients.Achievements and Challenges.CA Cancer J Clin; 58:214-230. [10] Kroenke CH, Kubzansky LD, Schernhammer ES, Holmes MD, Kawaichi I. 2006. Social Networks, Social Support and Survival after Breast Cancer Diagnosis. Journal of Clinical Oncology 1: 24(7): 1105-11. [11] Ng, C. G., Mohamed, S., See, M. H., Harun, F., Dahlui, M., Sulaiman, A. H., Zainal, N. Z. et al. 2015. Anxiety, depression, perceived social support and quality of life in Malaysian breast cancer patients: a 1-year prospective study. Health and Quality of Life Outcomes, 13(1), 205. doi:10.1186/s12955-015-0401-7. [12] Rodin G, Lloyd N, Katz M, et al. 2007. The Treatment of Depression in Cancer Patients: A Systematic Review. Support Care Cancer;15(2):123-136. [13] Srisvastava V, Ansari MA, Kumar A, Shah AG, Meena RK, Savanch P, Singh P. 2016. Study of Anxiety and Depression among Breast Cancer Patients from North India. Clinical Psychiatry, Vol (2): 1-4. [14] Yip, C. H., Pathy, N. B. & Teo, S. H. 2014. A Review of Breast Cancer Research in Malaysia. Medical Journal of Malaysia (69) August : 8 22. [15] Zigmond AS, Snaith RP.1983. The Hospital Anxiety and Depression Scale. Acta Psychiatric Scand, 67: 361-70. DOI 10.18502/kls.v4i4.2282 Page 240